SGD Report Structure
Demographics
Patient’s (Name):
Address:
Phone Number:
DOB:
Age:
SSN:
Patient’s Primary Contact Person:
Address:
Relationship:
Medical Diagnosis:
Date of Onset:
Speech-Language Diagnosis:
Date of Evaluation:
Date of Request:
Medicaid Number:
Medicaid Trial Start Date:
Physician:
School (Name):
Speech-Language Pathologist:
Occupational Therapist:
Physical Therapist:
Medicaid Trial End Date:
Phone Number:
Phone Number:
Phone Number:
Phone Number:
Background Information
1. Communication Impairment type and severity (Diagnosis)
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Describe impairment severity (How individual presents)
If the user currently has had a previous device you must state why it is no longer working for
(him/her).
o Is it un-repairable (per manufacturer’s documentation)?
o Can it still be repaired however the device has had extensive repairs in the past and
more are anticipated thus leaving the user without a voice for a long period of time during
repairs.
o Document frustrations the user has had while the device has been in for repair.
o Document if the user outgrown the language capabilities?
2. Anticipated Course of Impairment
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This section should demonstrate the current status and the expected course of the speech
impairment as it relates to the underlying medical disease and condition.
Indicate the expected course of impairment for conditions that are stable as well as those that
are progressive
Examples:
"(Name) exhibits severe dysarthria, secondary to the diagnosis of cerebral palsy. Dysarthric speech is
characterized by weak, slow and labored speech. (Name)’s dysarthria is severe and prohibitive of
intelligible speech so as to meet daily communication and medical needs. (His/her) condition is stable
and speech intelligibility is not expected to improve"
“(Name) exhibits severe apraxia secondary to the diagnosis of autism. Apraxia of speech is the result of
damage to the motor portion of the brain responsible for speech production. This inability to coordinate
muscle movements prohibits (Name)’s ability to produce intelligible speech so as to meet daily
communication and medical needs.”
"(Name) exhibits severe dysarthria secondary to the diagnosis of amyotrophic lateral sclerosis (ALS).
(Name)’s current speech rate is ## (half of normal), indicating precipitous decline in speech intelligibility.
Given the further weakening of the speech mechanism, and reduced vital capacity/ breath support,
intelligibility will continue to deteriorate. (Name) will require use of a SGD throughout the course of this
disease."
3. Prognosis with and without the aid of a speech generating device
Speech and Language Status
Comprehensive Assessment (Comment on each of the following areas as they pertain to using the
device)
Language Skills
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
Describe the level of linguistic impairment (no impairment to severe language
impairment) as it relates to the person's ability to use a SGD.
Consider describing:
o performance on any language assessments completed
o competency of ability to develop functional language skills
o type and level of symbol use by the individual. Does person require pictographic
symbols, words, letters, and/or a combination of symbols?
o linguistic capacity to formulate language/messages
o level of independence in formulating messages using language
Receptive Language:
Describe the patient’s receptive language skills based on current assessment.
Example:
“(Name)’s receptive language skills were judged to be a relative strength. (Name) demonstrates
comprehension of words, sentences and spoken language at the conversational level. When presented
with a set of pictures, (Name) identified the item depicted with 100% accuracy. Given a set of pictures,
and the function of a particular object presented orally, (Name) identified the picture that matched the
function with 80% accuracy. (Name) demonstrated the ability to follow directives ranging from simple
(one step), to more complex multistep directions. It was noted that (Name) excelled at completing multistep directions given visual displays and familiar routines. These areas of strength form the basis of an
excellent prognosis for communication development using a speech generating device (SGD). A device
that provides access to vocabulary to meet daily communication and medical needs in a picture/symbol
format will provide tools to bridge the gap between (Name)’s receptive and expressive language skills.”
Expressive Language:
Describe the patient’s receptive language skills based on current assessment.
Example:
“While (Name) is able to point, use some sign language and presents vocal approximations of words,
his/her expressive language abilities were judged to be severely limited. Speech production at the word
level is characterized as apraxic and effortful. (Name)’s speech sounds lack coordination of articulatory
movements and result in severely limited intelligibility. This struggle with natural speech production
contributes to extreme frustration for (Name) as exhibited by screaming in protest, as well as avoidance
and escape behaviors. Even with familiar communication partners, (Name) experiences difficulty and
frustration as it is often difficult to judge his communicative intent. Communication partners are often left
to wonder if he is sick, hurt or what particular need he is attempting to express.
During the trial with Tobii Dynavox (T10, T15, I-12, I-15, Lightwriter SL40), (Name) had access to
communication to meet daily needs. He was able to express himself by touching a picture or combination
of pictures. Given use of his SGD, (Name) was able to express (him/herself) with a clear articulate voice
for the first time. This resulted in decreased frustration and improved interactions with familiar and
unfamiliar partners. It also provided him a means to express his feelings, emotional and physical state.”
Oral Motor Status:
Describe the patient’s oral motor skills based on current assessment.
Example:
“The oral motor exam revealed an open mouth posture with low tone in the facial muscles. Facial
symmetry was noted. (Name) was able to imitate basic oral motor movements, but had difficulty with
coordination for more complex movements needed for intelligible speech.”
Pragmatic Language:
Describe the patient’s pragmatic skills based on current assessment.
Example:
“(Name) was able to sustain attention and focus during the evaluation. Although (his/her) diagnosis is
Autism, (he/she) is able to maintain focus, attention, and recall detail at a much higher level than was
expected. (Name) will respond to requests and demonstrated some initiation. Pragmatic language is
considered mildly impaired. (He/She) demonstrated appropriate greetings and departure behaviors.”
Speech-Language Prognosis:
Describe the patient’s speech and language prognosis based on the above findings.
Example:
“The speech and language difficulties associated with autism are long-term. While (Name) may
demonstrate improvement in these skills, the prognosis for (him/her) to become a functional oral
communicator is poor. However, given relative strengths in receptive language and his desire to interact,
(Name)’s prognosis for communication development using an SGD is excellent.”
Reading and Spelling Status:
Describe the patient’s reading and spelling capabilities as it relates to their communication.
Example:
“(Name) is able to read some basic words. (He/She) can spell (his/her) (Name) and some other common
words as well. When using the keyboard (he/she) was able to find the letter effectively and word
predication helped (Name) spell more difficult words. (He/She) is able to write some words as well, but it
is laborious. “
Cognitive Status
 Describe the level of cognitive impairment (no impairment to significant cognitive impairment) as it
relates to the person's need for and ability to use a SGD.
 Describe the person's alertness, attention span, memory, vigilance (how long they will stay on a
task) and problem-solving skills as they relate to using an SGD to enhance or develop daily,
functional communication skills.
 The report MUST state: The patient possesses the cognitive/linguistic abilities to effectively use
a SGD to communicate and achieve functional communication goals.
Examples:
“Receptive language abilities and cognition are highly correlated. (Name)’s cognitive abilities were
judged to be at or slightly below the level of his same age peers. (Name) quickly catches on to routines,
adapts well to redirection and perseveres when performing difficult tasks. When approached with a new
concept or task, (Name) accepts assistance and generalizes what he has learned to complete the task
independently (Give a specific example of (Name) eternalizing a concept and generalizing). (Name) has
a very strong memory and great attention to detail. Concepts presented are easily retained and used to
perform new tasks.”
“(Name)’s attention, memory and nonverbal problem-solving skills are within functional limits. He
sustained attention for the entire evaluation, recalled how to turn on and off a SGD (after initial
instruction), and independently navigated between two pages on a SGD. He has the attention, memory
and problem-solving skills to use an SGD to achieve his functional communication goals."
Physical Status:
 Describe pertinent considerations regarding motor skills, ambulatory status, positioning and
seating.
 Describe the patient’s range of motion and accuracy of movement.
 Describe how the person will access the SGD (direct selection, scanning) and the person's
access requirements related to positioning of the device.
 Describe if accommodations may be required over time to deal with changes in physical access.
 The report MUST state: "The patient possesses the physical abilities to effectively use a SGD
and required accessories to communicate."
Example:
“(Name) is ambulatory. Fine motor skills are adequate for accessing the (T10 or T15) with 40 buttons on
the screen. (He/She) is able to isolate (his/her) index finger for direct selection. (Name) possesses the
physical abilities to effectively use a SGD and required accessories to communicate."
Vision Status
 Describe the communicator's vision relative to using a SGD (along a continuum from normal
vision to blindness).
 Include the following elements if/when pertinent to SGD use/selection: acuity, visual tracking,
visual field, lighting needs, angle of view, size of symbols, contrast (color, detail), and spacing.
 The report MUST state: "The patient possesses the visual abilities to effectively use a SGD to
communicate functionally.
Example:
“Visual acuity and functional vision are within normal limits. (Name) demonstrated the ability to identify
symbols on buttons sized ¾ inches by ¾ inches with 100% accuracy. (Name) possesses the visual
abilities to effectively use a SGD to communicate functionally.”
Hearing Status
 Describe the communicator's hearing relative to communicating with a SGD (along a continuum
from normal hearing to deafness).
 Include communication partner's status, if relevant.
 Include specifics (if related to SGD use/selection) regarding acuity, localization, understanding of
natural speech, understanding speech generated by a SGD.
 The report MUST state: "The patient possesses the hearing abilities to effectively use a SGD to
communicate functionally."
Example:
“(Name)’s hearing status is within normal limits. He responds to sounds in his environment, follows
directions and interacts with individuals who produce speech at the volume of conversational speech.
(Name) demonstrated the ability to hear and understand speech coming out of his SGD as evidenced by
his error correction after hitting the wrong button and hearing the incorrect utterance coming out of his
device. (Name) possesses the hearing abilities to effectively use a SGD to communicate functionally."
Functional Communication Needs
This section should list the person's daily functional communication needs in areas described. Modify this
section for the needs of a child or adult:
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
Communication to enable the person to get physical needs met (e.g., ability to communicate in
emergency situations, directing behavior of family and/or caregivers, advocating for him/herself,
communicating with family, friends, school personnel, clergy and/or using the telephone)
Communication to enable the person to obtain necessary medical care and participate in medical
decision-making, (e.g., reporting medical status and complaints, asking questions of medical
providers, responding to medical provider's questions, discussing choices for end of life care,
communicating with medical providers by phone).
Example:
Child
“(Name) has a variety of daily communication needs. (He/She) needs to be able to communicate about
personal, social, emotional needs. (He/She) needs to communicate with family member, teachers,
therapists, and peers on a daily basis. Without a SGD, (he/she) has no means to indicate if (he/she) is
sick or give information if he were hurt. Specific communication needs include answering more detailed
questions, responding to comments, asking questions, conversing with others, generating novel topics or
ideas, expressing feelings, and making requests. (He/She) needs a SGD that will enable (him/her) to
express (himself to his highest potential with a number of communication partners in a variety of
environments.
Adult
“(Name) has a variety of daily communication needs. (He/She) needs to be able to communicate about
personal, social, emotional needs. (He/She) needs to communicate with family member, therapists, and
peers on a daily basis. Without a SGD, (he/she) has no means to indicate if (he/she) is sick or give
information if (he/she) were hurt. Specific communication needs include answering more detailed
questions, responding to comments, asking questions, conversing with others, generating novel topics or
ideas, expressing feelings, and making requests. (He/She) needs a SGD that will enable him to express
(himself/herself) to (his/her) highest potential with a number of communication partners in a variety of
environments.”
Ability to Meet Functional Communication Needs with Non SGD Approaches
This section should document why the patient is unable to fulfill daily functional communication needs
using natural speech (or speech aids) and non-SGD treatment approaches.
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Discuss success of speech therapy (to date and future prognosis) without a SGD
Discuss the individual's ability to use low-tech strategies and natural modes of communication to
met daily functional communication needs.
Discuss why a SGD is required in addition to, or instead of low-tech strategies, sign language,
writing and natural speech.
Show explicitly that other forms of treatment have been considered and ruled out.
Mention issues related to communicating with primary partners and caregivers in specific
contexts.
Example:
"(Name)’s daily functional communication needs cannot be met using natural communication methods or
low-tech/no-tech AAC techniques.
- Speech Therapy - (Name) has been receiving speech therapy services since the age of 2. Over
(his/her) course of treatment several communication systems have been employed starting with simple
signs. (Name) continues to demonstrate the ability to us and understand a very limited sign vocabulary.
- Sign language – Sign language is not a viable option for communication due to the physical limitations
of (Name) and the inability of most communication partners to understand this method of communication
This is not an adequate form of communication for (Name) as (he/she) is limited in (his/her) acquisition of
signs, and most people in his everyday environment are not competent in sign language. This limits
(his/her) communication partners and renders (him/her) unable to meet (his/her) daily communication
needs.
- Writing - Writing is not a viable communication method due to physical limitations of (Name) and
effectiveness due to lack of speech output.
- Communication symbols, communication boards and PECS – These methods limit communication to
the symbols provided in a book or board. Managing these symbols and having them readily available to
the individual during communication opportunities presents a challenge to independent, easily accessible
communication. Navigating through pages of language and/or individual symbol cut outs (usually with the
assistance of others) slows down or completely stops the communication process. Picture boards and
PECS have been used and not found to be an effective means of communication. The focus inevitably
shifts to managing the communication system at the cost of the individual independently communicating
preferences, wants and medical needs. Furthermore, these systems have no voice output, nor are they
able to create novel messages. Without voice output an individual cannot independently call for help or
direct attention to medical needs with someone who is not familiar with the system. Communication is
limited to communication partners who understand the symbols, and even then, the communication
partner is left to determine the intent behind an individual touching a particular picture symbol.
For these reasons, low tech and no tech options were eliminated from consideration.”
Trials with Various SGD’s
*** A trial period with each device is NOT REQUIRED; however the SLP must state which comparable
devices “were considered and ruled out for the following reasons.”
*** Must rule out all device codes/categories as well as comparable device***
Example:
The following devices were considered in this evaluation:
E2508: text to speech only (typing devices). An example of this type of device is the Lightwriter SL40. A
typing device will allow an individual to type a message into a device and press a button which
speaks. This device was quickly eliminated from consideration as typing is not an efficient mode of
communication for this individual.
E2510: synthesized speech, multiple access methods. An example of this device is the T10 and I-12.
These types of devices allow for text to speech message generation as well as combining symbols to
messages. (Rule out other E2510 devices considered and rejected)
E2510: Tobii Dynavox T10: Example: The T10 was considered and deemed as an inappropriate device
for (Name) as (Name) requires eye gaze interaction to access the device. The T10 does not have the
capability to utilize eye gaze as an access method.
E2510: Tobii Dynavox T15: Example: The T15 was considered and deemed as an inappropriate
device for (Name) due to the fact that (Name) does not have the capability to carry the T15. The T15
weighs 3lb. 13 oz. and (Name) would not be able to effectively carry the T15.
E2510: Tobii Dynavox I-12: Example: The I-12 was considered for (Name) and deemed inappropriate
for (Name) as the device is too heavy weighing 6.2 lbs. and (Name) does not possess the physical ability
to carry this device consistently without being at risk of falling.
E2510: Tobii Dynavox I-15: Example: The I-15 was considered for (Name) and deemed inappropriate
for (Name) as the device is too heavy weighting 8.4 lbs. (Name) does not currently possess the physical
ability to carry this device consistently without being at risk of falling.
The report MUST state:
"Using my clinical expertise, I (SLP name) have determined that the Tobii Dynavox (T10, T15, I-12, I-15,
Lightwriter SL40) device is the most appropriate communication device for (Patient Name). (Name) has
had a trial with the Tobii Dynavox (T10, T15, I-12, I-15, Lightwriter SL40) device, therefore I am
requesting a direct purchase of this device for (Name)."
General Features of the Recommended SGD
This section will explain why certain device features are required. The rationale will relate the patient’s
skills and abilities as described in the Physical Status section.
The report MUST state:
"This individual requires a speech generating device with (list specific features) to meet the person's
functional communication goals."
Input Features/Selection Technique
A. Patient requires access through Direct Selection via touch
 Keyboard with access to dynamic display screens with adjustable number of selections/buttons
on each screen.
 Touch sensitive screen with adjustment options to improve accuracy
B. Patient requires access through Direct Selection via HeadMouse or Gaze Interaction (if needed)
 Optical pointer, head mouse, eye gaze, other (if needed)
C. Patient requires access through Scanning via a switch (if needed)
 Display: number of keys, dynamic/static
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Mode: visual or auditory scanning
Type of scan: linear, row/column, group/row/column, directed (joystick, trackball), adjustable
speed
Switch: type (pressure, feedback), position, mount
C. Encoding Type
Message Characteristics/Features
A. Type of Symbols
 Color PCS symbols, access to scene based language, real pictures for easy access to language.
B. Storage Capacity
 Ability to produce messages of varied length
 Ability to store a large number of messages for improved speed and access.
 Other (specify)
C. Vocabulary Expansion and Rate Enhancement
 Vocabulary organized in levels with access to real scenes which reduce cognitive load and
provide context. Access to Quickfires, Quick Phrases and common constructions
 Word prediction
 Other (specify)
Output Features
 Voice with intelligible lifelike voices
 Highly salient visual display
 Auditory and visual feedback when pressing a location on the screen.
Other Features (NOTE: These relate to AAC accessories)
 Portability to be used in various environments throughout the day
 Size and weight, transport/mount, case/carrier requirements
 Battery time required
Description of Equipment Used and/or Considered During the Evaluation
 Include evidence that the individual was present and actively participated in the assessment
process. Discuss assessment outcomes that demonstrate the person's ability to use the SGD and
recommended accessories.
 Discuss other access methods tried and why they are unsuccessful. Please remember to be very
explicit in your reasons that other access methods failed. If a HeadMouse or Gaze Interaction is
needed, please be very specific in reasons for ruling out scanning.
 If a ConnectIt mount is needed, please justify why the mount is needed and how it will be
positioned for optimal use of the SGD.
 Discuss other SGD’s used and/or considered and why they were not appropriate for this user.
You do not have to try each device considered with the user if it can be ruled out without a
trial.(see the following example)
SGD and Accessories Recommended
List the specific SGD, accessories and mounting components and include medical justification as to
why this SGD and specifically the accessories being requested will enable the individual to achieve
functional communication goals, as stated earlier in the report.
Example:
“The (insert device name), also include the selection method accessory is asking for one) is medically
necessary because it will correct (Name)’s inability to speak and aid (Name) in preventing other health
and safety issues from arising by allowing (Name) to express him/her self. Through the use of the icons
and pre-programmed language, (Name) should be able to recapture many of (his/her) expressive
language skills and prevent any additional loss of (his/her) receptive skills. For instance, if (Name) has a
dental appointment he/she can program her device to explain to the dentist what tooth is bothering
(him/her), for how long and at what intensity. This device is also flexible enough to provide (Name) with
spontaneous speech through the use of an alphabet keyboard so (he/she) can address her immediate
needs. Because (Name) is spastic she has very little residual use in her arms. Therefore, as a primary
consideration for selecting the device which will best meet (Name)’s needs; additional consideration must
be given to the over-all accessibility of the key board. The (device name) was selected because its key
board uses larger common language icons for needs such as toileting and feeding and larger alphabet
keys for spontaneous speech. These larger icons and keys will assist (Name) in effectively
communication by allowing him/her to touch any part of the key or icon for selection while providing
sufficient space between the keys or icons to minimize mistakes in selection.”
The report MUST state:
"(Name)’s ability to achieve (his/her) functional communication goals requires the acquisition and use of
the (device name) and (state the specific accessories). This SGD represents the clinically most
appropriate device for (Name). Using my clinical expertise, I have determined that the (device name) is
the most appropriate communication device for (Name). (Name) has had a trial with the (device name),
therefore I am requesting a purchase of this device for (Name).”
See Examples Below:
E2510 Tobii Dynavox T10
(Name)’s ability to achieve his/her functional communication goals requires the acquisition and use of the
Tobii Dynavox T10. As stated above, (Name) does not use oral language to communicate. (Name)’s use
of sign language is limited to 1-2 word utterances which typically are repetitions of language presented to
(him/her) by (his/her) communicative partner. (Name) demonstrated immediate and sustained
language/communication growth throughout (his/her) trial using the Tobii Dynavox T10. (He/She)
produced utterances of increased length and syntactical complexity, answered simple questions, and
participated in academic activities with increased success.
(Name) is fully ambulatory, and communicates within and between multiple environments. Therefore, a
carrying case is warranted to provide (him/her) with easy access to the device. The case and shoulder
strap will and reduce the risk of (him/her) dropping the device causing damage and expensive repair.
Using my clinical expertise, I have determined that the Tobii Dynavox T10 is the most appropriate
communication device for (Name). (Name) has had an adequate trial with the Tobii Dynavox T10;
therefore I am requesting a direct purchase of this device for (Name).
Example statements for other accessories
The following accessories are also being requested to meet (Name)’s medical needs:
E2512 Wheelchair Mounting System – to position the SGD in the optimal place for effective visual and
physical access of the device. Please be explicit with reasons as to why you are recommending the wheel
chair mount.
Wheelchair Information for Mounting System:
Make:
Model:
Switch Mount – this mount is necessary to position the switch in the proper place for optimal use.
E2599 User Accessible Carry Case – for protection of the device while be used throughout the day and
during transport
E2599 Keyguard – Given the (Name)’s physical status and performance during the evaluation period, a
___ location keyguard is warranted. (Name) was observed using the requested SGD without a keyguard.
(Name) frequently rested his hand on the screen or activated an adjacent button. This resulted in
misshits and inaccurate messages being accessed. A keyguard is a raised plastic piece with holes cut
out encompassing each location on the page. When the keyguard was applied, accuracy was greatly
improved. (Name) was able to rest his hand on the keyguard and access the intended message without
difficulty. A keyguard is medically necessary for (Name) to meet his daily communication needs.
E2599 Headmouse or Tracker Pro – this is an alternate access device where the user will move their
head to control a pointer on the screen. This pointer will activate the desired square when the user dwells
on it.
E2599 EyeGaze Technology
 If eye gaze technology is recommended (I-12 or I-15) Sample Rationale:
o Gaze Interaction will allow (Name) to access the (I-12 or I-15) using no body movements
other than the pupils of (his/her) eyes. (Name) has no well controlled body parts to use
other access methods. There are no other options of access other than eye gaze
interaction. (He/She) does not have head control to access a Headmouse accurately or
use scanning for switch access.
Goals for Implementation/Treatment Plan
An Augmentative and Alternative Communication (AAC) therapy treatment plan for the member which
includes the following:
- the party responsible for delivering and programming the speech generating device;
- a statement as to who will train the member and communication partners in the proper use,
programming, care and maintenance of the speech generating device;
- the short and long term goals and expected outcomes
- a description of the criteria to be used to measure the member’s progress toward meeting both short
and long-term communication goals and expected outcomes
Intervention Schedule
Address all functional communication goals previously stated for the beneficiary and identify the plan for
achieving these goals using the SGD and accessories.
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Frequency of SLP treatment
Type of Treatment (individual vs. group)
Projected Frequency of Reassessment
Follow-up Requirements for SGD and Accessories
o Individual(s) responsible for programming
o Individual(s) responsible for troubleshooting
Patient/Family/School Support of SGD
 Discuss participation of the family/caregiver/advocate and state that they agree to the selected
SGD and will support the equipment and its use for daily communication.
Physician Involvement Statement
This report was forwarded to the treating physician
(Name) ________________________________________
Address ______________________________________
City, State, Zip _________________________________
Telephone # __________________________
A copy of this report will be forwarded to (Name)’s treating physician on _______(date), so that (he/she)
can write a prescription for the recommended SGD and accessories.
SLP Assurance of Financial Independence and Signature
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The report MUST state: "The SLP performing this evaluation is not an employee of and does not
have a financial relationship with the supplier of any SGD."
SLP signature
Evaluating SLP's (Name) & contact information (agency, address & telephone number)
ASHA Certification Number
This report has been drafted pursuant to the ethical guidelines of the American Speech and Hearing Association. As per
the Communication Bill of Rights, “all persons with severe disabilities have the right to communicate to affect those
conditions that impact their life.” (Established by the Joint Committee for the Communication Needs of Persons with
Severe Disabilities.